(ADDRESS)
(BRAND NAME)
(BRAND NAME)
(BRAND NAME)
(BRAND NAME)
(BRAND NAME)
(BRAND NAME)
(BRAND NAME)
(BRAND NAME)
(BRAND NAME)
(BRAND NAME)
(BRAND NAME)
(BRAND NAME)
(BRAND NAME)
(BRAND NAME)
(CLEAR) CLEAR
(DATE)
(EMAIL ADDRESS)
(NAME OF AUTHORIZED AGENT (typed or printed))
(PRINT) PRINT
(TELEPHONE NUMBER)
(TITLE)
(TOBACCO PRODUCTS MANUFACTURER/IMPORTER NAME)
94279 0088 If more space is required you may copy this form
additional brand is manufactured or imported by the reporting company or a listed brand is no longer manufactured or
ADDRESS
As required by the California Cigarette and Tobacco Products Licensing Act of 2003 (California Business and Professions Code
BOARD OF EQUALIZATION
BOE 400 LT1 REV 4 (5 12)
BRAND NAME BRAND NAME
Complete this schedule and mail it to the Board of Equalization Special Taxes and Fees P O Box 942879 Sacramento CA
eligible for obtaining and maintaining a license a manufacturer or importer must submit to the Board of Equalization (BOE) a list
EMAIL ADDRESS
imported by the reporting company To obtain additional copies of this form please visit our website at www boe ca gov or call
NAME OF AUTHORIZED AGENT (typed or printed)
of all tobacco products brand families that it manufactures or imports
our Taxpayer Information Section at 800 400 7115 (TTY:711)
Pursuant to Chapter 4 of the California Business and Professions Code (commencing with section 22979) in order to be
SCHEDULE OF TOBACCO PRODUCTS BRAND FAMILY NAMES
section 22979 21) the reporting company must update the schedule and provide a copy to the BOE whenever a new or
SIGNATURE OF AUTHORIZED AGENT
STATE OF CALIFORNIA
TELEPHONE NUMBER
TITLE
TOBACCO PRODUCTS MANUFACTURER/IMPORTER NAME
